Provider Demographics
NPI:1487694097
Name:MARTINO, RICHARD P (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:P
Last Name:MARTINO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 N WESTMORELAND RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:847-234-3390
Mailing Address - Fax:847-234-3391
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:SUITE 208
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-234-3390
Practice Address - Fax:847-234-3391
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0106X, 122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Not Answered122300000XDental ProvidersDentist
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL524480Medicare ID - Type Unspecified
ILT37088Medicare UPIN